Van den Bergh,Frances • I'itrc; Vic.:ev C��„�t:c;c•y �c �..1'CGIrriU.C)tlUltl
Quaker Road
QUCCI bury, NY 128011.
or (.518) 74,5-1I•476
['uneral (-lotnc
lZe<luest.ed Return _ _ _
Name -_l
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_.-..._........__�.:t51 No.
Date of Cremation 111 ti I I 2 'r
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Placed in -Cold: "-
Placed in Rcfrige ratiocr:
Placed in Retort: _--_- qq
^I•yltc of Container
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Remarks
Main
Move_.._.._.
Place of Deatlt ?9
[stiniat-ed Weigh(. ol• Rctmrins and Coruairtcr_—__
Date&"('imc Rc,rrairrs a►rivccl at.Creutat.oi t
Name of Ftjljcral DircCtor or Registered Resident. Dclivca-inl;
Detailcd reason for cic;lay il•rcnrrins were c:rentmacd more than 1IH hours from time oFaccel>ted
delivery
Retort Number in which Remains were crcur,c�ccl
Noic Tile CG•e;ntalion shall Itc relainecl in the l'cr1tt,uteut. I ilc of tlic Cren►:uctry --- __
New York State
Department of State
NEW YORK DIVISION OF CEMETERIES
STATE OF Division of One Commerce Plaza
OPPORTUNITY_ Cemeteries
99 Washington Avenue
Albany,NY 12231-0001
Telephone:(518)474-6226
www.dos.ny.gov
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
11/08/2019 Q
Date: Number:
Crematory Name: Pine View Crematory
Address: Quaker Road, Queensbury, NY 12804 Phone: 518-745-4477
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing the remains of the deceased and the container holding the remains into a cremation chamber where
they are subjected to intense heat and flame. The heat and flame will incinerate and consume everything except bone and metal,
which are all that will be left after cremation.
Following cremation,the crematory will take reasonable efforts to remove all of the remains and other material from the cremation
chamber, but some minimal dust and residue will likely be left behind. The crematory will separate incidental and foreign material from
the remains and the incidental and foreign material will be disposed of as required by law. The cremated remains will be mechanically
pulverized into small pieces and placed into a designated container or urn. Cremated remains generally are pulverized until no
single fragment is recognizable as skeletal tissue.
OPENING OF THE CONTAINER
The crematory may only open the container holding the un-cremated human remains in limited circumstances, such as to confirm the
identity of the deceased or to ensure that no material is enclosed which might injure employees or damage the crematory property. If
human remains are delivered in a container which is not suitable for cremation such as ceremonial or rental casket,the
crematory will require that the remains be moved into a suitable container before it accepts the remains. The opening of a
container or the transfer or removal of remains will be conducted before a witness and will be done in privacy,with dignity and respect.
IDENTIFICATION OF DECEAQq0'J')
Frances denk J - Married
Name of Deceased: Marital Status:
88 First Ave.,Apt A, Hadley, NY 12835
Last Known Address:
88 First Ave.,Apt A, Hadley, NY 12835'
Place of Death:
c/ 11/07/2019 125
Sex: ❑ ME] F Age: &c DOB: a 5/50 Date of Death: Estimated Weight:
Description of casket/container in which remains will be delivered.
Basic Cremation Container; MacDonald Cremation Container;cardboard
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition, initial ONE of the following)
I am/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Law Section 4201.
- R-� I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
will containing directions for the disposition of his or her remains and I/we are the person(s)having priority under Public Health Law
Section 4201 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased is as
follows: YAY) 1_
Frances
(Name of Deceased)
DOS-1898-f(Rev. 08/15) Page 1 of 3
s
Authorization for Cremation and Disposition
Initial the following)
` I/We understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory
may dispose of the remains in
(Name of Crematory)
an irretrievable manner, such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
An urn to be used as a container for the cremated remains has been purchased from
and is described as follows:
I/We understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
-OR-
An urn is not yet purchased. I/We understand that if no urn is purchased or otherwise provided
Pine View Crematory
will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
This Authorization Form was provided by Patricia Miller was executed at
(Funeral Director Name)
Brewer Funeral Home, Inc.
24 Church St., Lake Luzerne, NY 12846. MIIIIII
and is signed by the funeral director as witness to its execution.
I/We have received a completed copy of this Authorization Form.
The person(s)identified below is/are the person(s)in control of disposition,who by signing this Authorization Form,attest(s)
to the accuracy and completeness of the information contained in this Authorization Form and authorize(s)the foregoing.
08 November 19
Signed this day of .20
fax NAN -r►N(Z(ATyped or or Printed Name '�ff�//II Signature
?g f',;i- �1 fttt Ant A N'4f�1 I IZZ7
Address
Typed or Pnnted Name Signature
Address
Typed or Pnnted Name Signature
Address
WITNESS:
Patricia Miller }; `
(Funeral Director Typed or Pnnted Name) (Funeral Director Signature)
12465
(Registration Number)
Frances VQ.Y1 d-e*, Bcr
(Name of Deceased)
DOS-1898-f(Rev. 08/15) Page 3 of 3